When and how should urinary catheterization be performed?

Urinary Catheterization: When and How to Perform

Avoid indwelling urinary catheters whenever possible and use intermittent catheterization as the first-line approach for bladder management, reserving indwelling catheters only for specific clinical indications and removing them as early as possible to minimize infection risk and complications. 1, 2, 3

Appropriate Indications for Catheterization

Indwelling Urinary Catheter Indications

• Severe urinary retention or bladder outlet obstruction 3
• Wound healing in the sacrum, buttocks, or perineal area 3
• Prolonged immobilization (e.g., unstable pelvic fractures, severe neurological injuries) 4, 3
• Palliative care for terminally ill patients 3
• Acute monitoring needs in hemodynamically unstable patients requiring strict fluid balance (sepsis, acute physiological derangement) 4
• Following surgical repair of bladder injuries (urethral catheter without suprapubic tube) 4

Intermittent Catheterization Indications (Preferred)

• Acute or chronic urinary retention with post-void residual (PVR) >100 mL on three consecutive measurements 1, 5, 3
• Bladder volumes approaching or exceeding 500 mL 1, 5
• Sterile urine testing or PVR assessment 3
• Spinal cord injury patients (as soon as medically stable) 4, 2

Contraindications to Catheterization

Never use catheters for:

• Staff or caregiver convenience 3
• Incontinence-related dermatitis 3
• Urine culture procurement from a voiding patient 3
• Initial incontinence management 3

Clinical Decision Algorithm

Step 1: Initial Assessment (0-72 Hours)

• Use bladder scanning to assess PVR rather than catheterization when possible 1
• If PVR <100 mL consistently for 3 consecutive measurements, discontinue monitoring 1
• If PVR >100 mL or patient has symptoms (bladder discomfort, inability to void, overflow incontinence), proceed to Step 2 5

Step 2: Determine Catheterization Method

For urinary retention (PVR >100 mL):

• Institute intermittent catheterization every 4-6 hours to prevent bladder volumes >500 mL 1, 5
• Continue until PVR consistently <100 mL for 3 consecutive measurements 1

For indwelling catheter (if unavoidable):

• Use silver alloy-coated catheters 2
• Evaluate daily for removal 4
• Remove as soon as strict fluid monitoring no longer required, patient mobilizes, or epidural analgesia discontinued 4

Step 3: Special Considerations in Trauma

Before catheterization in pelvic trauma:

• Perform retrograde urethrography if blood at urethral meatus is present 4
• Position patient obliquely (bottom leg flexed, top leg straight) or supine if severe fractures present 4
• Inject 20 mL undiluted water-soluble contrast via 12Fr Foley catheter in fossa navicularis 4
• Avoid blind catheter passage before imaging 4

Urethral injury management:

• Partial injuries: Single attempt with well-lubricated catheter by experienced provider acceptable 4
• Complete disruption: Suprapubic cystostomy or delayed repair 4
• Pediatric patients with posterior urethral injury: Suprapubic cystostomy recommended 4

Bladder injury management:

• Intraperitoneal rupture: Surgical repair required 4
• Uncomplicated extraperitoneal rupture: Urethral catheter drainage for 2-3 weeks 4
• Complicated extraperitoneal rupture (exposed bone, concurrent rectal/vaginal injury, bladder neck injury): Surgical repair 4
• Post-repair: Urethral catheter alone (no suprapubic tube) for shorter hospital stay and lower morbidity 4

Intermittent Catheterization Technique

Frequency and Volume Management

• Perform every 4-6 hours to maintain bladder volume <500 mL 1, 5
• Goal: PVR <100 mL 1
• Use voiding calendar to adapt frequency and schedule 4

Technique Selection

• Clean technique acceptable for home use 6
• Aseptic technique required in institutional settings (hospitals, nursing homes) 6
• Self-intermittent catheterization is the reference method for long-term management 4

Duration Limits and Removal Criteria

Indwelling Catheter Duration

• Remove as early as possible—infection risk increases dramatically with time 1
• Urinary retention most common in first 72 hours after acute events (affects 21-47% of stroke patients) 1
• Standard duration after bladder repair: 2-3 weeks, though longer acceptable with significant concurrent injuries 4
• Beyond 7-10 days: Transition to intermediate-term management strategies if catheterization cannot be discontinued 1

Daily Evaluation Protocol

• Assess need for catheter daily 4
• Remove when: patient no longer requires strict fluid management, patient mobilizes, sedation discontinued, or epidural analgesia stopped 4
• Consider daily reminder or stop order systems to prompt removal 1

Infection Prevention Strategies

Essential Preventive Measures

• Handwashing before and after catheter manipulation 1
• Maintain closed drainage system 1
• Secure catheter to prevent traction and trauma 1
• Ensure adequate hydration 1
• Maintain good patient hygiene 1

Monitoring for Complications

• Monitor for UTI signs: fever, mental status changes 1, 5
• UTI incidence in catheterized patients: 10-28% 1
• If UTI develops: obtain urinalysis and culture, treat based on sensitivities, remove or replace catheter if feasible 1

Long-Term Catheterization (Last Resort Only)

When All Other Options Have Failed

• Reserve permanent catheters as last resort when all therapies for overactive bladder or retention have failed, are contraindicated, or patient no longer desires them 2
• Always use shared decision-making due to significant risk of harm 2

Suprapubic vs. Urethral for Chronic Use

Suprapubic catheter preferred for long-term use: 2

• Lower probability of urethral damage, trauma, and erosion
• Allows maintained sexual activity
• Risks: Intestinal perforation or vascular injury during placement, tissue granulation, bleeding, site erosion

Required Patient Counseling

Before permanent catheterization, inform patients about: 2

• Urethral trauma and erosion
• Urethral loss
• Bladder stones
• Chronic infection
• Increased risk of bladder cancer

Critical Pitfalls to Avoid

• Do not leave indwelling catheters for convenience—UTI incidence is 10-28% and leads to decreased functional outcomes and increased length of stay 1
• Do not allow bladder overdistention—volumes >500 mL cause detrusor muscle damage 1
• Do not place indwelling catheter for isolated elevated PVR without symptoms—this increases UTI risk without clear benefit 5
• Do not ignore PVR >100 mL in stroke or neurological patients—this population requires scheduled intermittent catheterization 5
• Do not perform blind catheter passage in pelvic trauma with blood at meatus—obtain retrograde urethrography first 4
• Do not routinely place suprapubic tubes after bladder repair—urethral catheter alone has shorter hospital stay and lower morbidity 4

Exceptions Requiring Suprapubic Catheterization

• Pediatric patients after posterior urethral injury repair 4
• Severe neurological injuries (head and spinal cord) requiring long-term catheterization 4
• Complex bladder repairs with tenuous closures or significant hematuria 4
• Associated perineal injuries 4
• Concomitant urethral injury in bladder trauma 4

Urologist Referral Indications

Refer when: 3

• Recurrent urinary tract infections
• Acute infectious urinary retention
• Suspected urethral injury
• Substantial urethral discomfort
• Long-term catheterization being considered